Enterprise Utilization Clinical Decision-Making Governance Lead

Become a part of our caring community and help us put health first
 Become a part of our caring community and help us put health first for our members, providers and ourselves.

Desired Lead Associate to lead and manage the enterprise framework to facilitate and document consistent clinical decision making. This includes ensuring appropriate monitoring controls are in place as well as ensuring identified opportunities are addressed. They will work closely with established functions inside utilization management (Medical Director, clinician decision making teams, quality audits, prior authorization list and clinical policy) as well as enterprise support teams (process, risk, strategy, delegate oversight teams and regulatory compliance). As needed, they facilitation MD to MD discussions to support education and awareness of enterprise standards for application of UMC approved clinical criteria. Finally, this team works closely with Clinical Risk Management to support enterprise MD speaker readiness for external audits or other inquiries.

Specific responsibilities

Oversight of enterprise controls based on the established pillars for consistent clinical decision-making: self-identification, quality oversight and monitoring, calibration on criteria, and continuous process improvement.

• Building our simple framework processes.
• Documentation of controls and expectation for clinical decision making.
• Interfacing with established controls provided by quality audit, clinical policy, process policy/documentation and reporting teams.
• Established thresholds for monitoring and identifying appropriate actions when controls indicate process gaps.
• Review appeal overturns and provider complaints about coverage policies to make necessary changes.
• Driving continuous process improvement including supporting UM strategic initiatives.
• Identify potential gaps between the intended application of coverage policies versus the actual application of clinical reviewers.
• Recommend enhancements to the coverage policy template to help ensure consistent and accurate interpretation and application of coverage policies.
• Support decision template development process to help ensure that templates aligned with coverage criteria and regulatory and accreditation requirements.

Center of excellence and support for requirements and expectations for UM Delegates and internal partners.

• Proactively identifies potential risks and impacts to UM delegates based on Humana Business Decisions
• Manages Humana-to delegate discussions for consistent clinical decision making
• Ensures business decisions.
• Support Delegation Compliance, delegate business relationship owners, strategy teams and National delegate oversight and support team on UM issues.
• Evaluates available data on delegate clinical decision-making and partners with clinical risk and regulatory compliance to evaluate specific action to mitigate detected risk.
• Supports PAL/clinical policy intake processes when there is malalignment with PAL codes and clinical policy changes.
• Manages appeal process for delegate …